Abstract
At our Institution, patients developing de-novo donor specific anti-HLA antibodies (DSA) early after lung transplantation were treated preemptively with therapeutic plasma exchange (tPE) and Rituximab until April 2013 and, since May 2013, with human intravenous immunoglobulins (IVIG) and Rituximab. Aim of this study was to evaluate the efficacy of IVIG vs. tPE protocols. Records of patients transplanted between January 2009 and September 2014 were retrospectively reviewed. Patients treated with tPE underwent sessions of 3 or 5 tPE only during initial hospitalization after lung transplantation. Patients treated with IVIG initially received 1g/kg body weight IVIG loading-dose, followed by additional courses of 0.5g/kg IVIG every four weeks until DSA clearance or to a maximum of 6 months. Patients received a single dose of Rituximab (375mg/m2) at the end of the first tPE session or IVIG loading-dose. DSA treatment was performed preemptively before appearance of graft-dysfunction. Among 694 transplanted patients, 57 (8%) patients (Group A) and 43 (6%) patients (Group B) underwent DSA treatment with tPE or IVIG, respectively. There was no difference among groups regarding preoperative characteristics. Postoperatively, more Group B than A patients developed class II DSA (91%vs.68%, p=0.008). Forty-nine (86%) Group A and 39 (91%) Group B patients received only one tPE session and one dose of IVIG, respectively. At discharge, more Group B than A patients showed DSA (71%vs.50%, p=0.05). At follow-up, no Group A patients underwent additional tPE. Instead, 34 Group B patients underwent 3±2 additional IVIG courses. At last DSA control, after having censored Group B patients (n=9) who have still not completed the IVIG protocol, 13 (27%) Group A and 4 (12%) Group B showed DSA (p=0.10). At 1-year follow-up, there was no difference among groups regarding freedom from steroid-pulsed therapy (p=0.1) and biopsy-proven rejection (p=0.78). Overall survival was significantly better in Group B patients (p=0.01). The IVIG protocol achieved satisfactory DSA clearance after repeated therapy courses. A combination of the two protocols may further improve DSA clearance. Further studies are warranted.
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